Women’s mental health online referral form

Medical professionals can submit a referral form online. Complete the details below and once submitted, the referral form will be automatically sent to wmh@cabrini.com.au.
For further enquiries, please email wmh@cabrini.com.au or phone (03) 9508 5100.

Patient Details
Client's name*
First Last
DOB*
DD slash MM slash YYYY
Phone number*
Aboriginal or Torres Strait Islander?*
- Yes
- No
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Health Fund details - If known
Health Fund Name
Member number
Exp. date
Client’s number on Medicare card
Please enter a number from 1 to 1.
Next-of-kin details - If known
Name
First Last
Phone number
Name
First Last
Phone number
Relationship to client
Referring Psychiatrist/GP details
Name*
First Last
Phone*
Practice details*
Reason for admission
Reason for admission*
Has the patient been admitted to a Private facility in the last 7 days?*
- Yes
- No
Psychiatric History (diagnoses, medications etc.) and Medical History*
Any other relevant details
Details
Attachment 1
Max. file size: 64 MB.
Attachment 1
Max. file size: 64 MB.
How did you hear about our Women’s Mental Health service?*
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